Psychiatria Danubina, 2017; Vol. 29, Suppl.

3, pp 409-415 Conference paper

© Medicinska naklada - Zagreb, Croatia

PERCEPTION OF BODY IMAGE IN EARLY ADOLESCENCE. AN

INVESTIGATION IN SECONDARY SCHOOLS
Maria Rosaria Juli
Family Counseling of Foggia, Foggia, Italy

SUMMARY
Introduction: The clinical evidence shows that the onset of eating disorders is increasing in the prepubescent phase or even in
childhood. Already starting from the prepubescence the certainties related to the body start to unwind and the individual is
encouraged to build new ones, based both on the anatomic transformation of his/her own body and on the social expectation
according to the identity.
The onset of a Eating Disorders is normally between 13 and 25 years, but in the last years we recorded a lowering in the onset
threshold to an age between 11 and 13 years, with some earlier cases at 7 years (Franzoni et al. 2012).
Many theories consider body dissatisfaction as the immediate antecedent to the development of this eating disorder. Different
studies have confirmed that a strong concern for physical appearance could sometimes precede an eating disorder (Cuzzolaro 2004).
The alteration of the body image is the major predictive factor for the relapse, the patients themselves refer that it is one of the major
obstacles for the realization of a lasting recovering. In the following study one hundred kids between 10 and 15 years old, without
any Eating Disorders diagnosis, have been tested to evaluate whether if already from this age there is a concern about body image
starting at this age, the fear of gaining weight and the desire to be slimmer. It is known, indeed, that these factors, if significantly
present in a subject, can turn into predictive factors of a psychopathology.
We need to build our body image over time; changing our percertion of reality can change also what we see, in particular the
body image we strive for changes (Bianchini 2008).
Method: 100 teenagers split in 53 females and 47 males aged between 10 and 14 years, randomly picked in the secondary
school.
Results: The results of the study show that in the age between 10 and 15 years the concern for the body shape is already present,
without difference between the genders.
Although 45% of the sample is underweight, the Figure Raiting Scale test both males and females want to be of lesser weight. 91
subjects reached a BSQ test score of over 34, so most of the sample has a strong concern for their physical appearance. The results
obtained by administering the BUT test also highlighted concern about the body with moderate gravity.
Discussion: Body dissatisfaction, as so many studies have confirmed, can be considered a precursor of psychopathology.
Concerns concern both female gender and male gender. It is also necessary to pay close attention to the pressure exerted by family
members, friends and the media towards a difficult to reach thinness ideal. That is why we need to focus on strengthening protective
factors in adolescents with prevention and awareness campaigns which are properly targeted.
Conclusion: The work resulted a useful reflection on the building of the body image as an early risk factor for the onset of
pathologies linked to this concept. We need to commit to an educative practice of support for adolescent, recognition and sharing,
which does not avoid the presence of the adults, but in fact it is enriched.
It would be appreciated if we could introduce in the school, in the program of different subjects, the discussion regarding
different aspects of a healthy nutrition and the formation of a solid self-esteem in order, for the students, to have a critical
interpretation of the media message on food, body and beauty.
It is desirable to promote the emancipation of the adolescents from a condition of dependence to discover their own place in the
world. The educative action can help developing the research of the meaning of the own personality.

Key words: Teens and body image - perception of the body image

* * * * *
Introduction
Eating disorders are defined as weight-control
behaviors that damage physical health and psychosocial
functioning and are not secondary to any known
medical or psychiatric condition. At an early age,
problems linked to nutrition are a common condition
with a very variable clinical relevance. Indeed, in addi-
tion to temporary events that especially happen during
some critical evolutionary stages such as weaning,
switch to eat alone, etc., there are also very serious
pictures characterized by a total refusal of the food with
an important impact on the physical and psychological
development of the child (Juli 2016).
The current diagnostic classifications of eating
disorders (DSM V, E ICD-11) consider these disorders
as one unique category called “Eating disorders of the
early childhood and childhood”.
Since the ‘50s of the last century we could notice a
gradual increase of the Eating Disorders (Dalle Grave,
2011) so that in the National Prevention Plan it is stated
that: “The spread of eating disorders is really fast and
significant: there is no other example of psychiatric
illness with such propagation and with the same
characteristics of a real social epidemic" (Ministry of
Health 2010).
At the same time it a decrease of the age of onset has
been recorded (Favaro 2009) so that there are more and

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Psychiatria Danubina, 2017; Vol. 29, Suppl. 3, pp 409-415
more often diagnosis before the first early period,
including cases of girls 8/9 years old (Dalla Ragione
2012). Therefore, currently it is necessary to pay more
attention to the pre-adolescence period because a long
delay is still occurring before defining the diagnosis that
can have a negative impact on the therapeutic diagnostic
path and on the prognosis of Eating Disorder (American
Accademy of Pediatrics 2010).
In the sector of clinical research on eating disorders
many useful tools for the study of body image have
been developed together with methodologies of inves-
tigation about perceptual aspects (Thompson 1995).
Indeed, it is well known that the alteration of the image
we have about our body has an important role in the
onset of Eating Disorders (Dalla Ragione 2005).
The scientific interest for clinical issues related to
the body image has determined a progressive elabora-
tion of a wide and various number of methods, tech-
niques and tools to evaluate the different components of
the mental representations.
In line with the traditional psychology, the research
has been mainly focused on deeper theoretical studies
and on the measurement of the behaviors and patho-
logical or anyway negative approach that some people
have regarding their body.
The founding father of the current theories on the
development of body image is Paul Schilder, author of
the first work entirely dedicated to the body image
called "The image and the Appearance of the Human
Body" (1935). Schilder can be considered as the starting
point of all the next works about body image, even if he
treated the topic especially from a neurological point of
view.
Nevertheless, the work of this author can still be
considered very valid in terms of studies about body
image; for body pattern he means the mental repre-
sentation of the body in its spatial and postural tonic
disposition, directly influenced by the related sensations;
for body image he means a further level of integration of
the body pattern with the emotional/cognitive context.
The study suggests, through the use of self-admi-
nistered tests to investigate within a preadolescent
group, perception of body image, body weight dis-
satisfaction, predictive factors for the birth of psycho-
pathology.
In particular, we are aiming at understanding if the
perception of the body image that children themselves
have is the same as the real one and also how to inter-
vene in a broader perspective by raising awareness and
promoting a primary prevention aimed at solving the
problems closely related to the perception of the image
of the body. Adolescence represents a critical phase of
the life cycle, especially as regards the formation of the
self-image and the body pattern. The relationship with
food in this age group is of fundamental importance not
only for the growth and development of the body, but
also as a symbolic value that contributes to defining
personal identity and psychosocial autonomy. The risk
factors for an early DCA debut are certainly increased:
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the patterns of the thinness to which children are
increasingly exposed through the mass media, but also
through the family, the school, and the aggregation
sites; Bad habits and less and less regular in the family.
This work, carried out by 100 students aged between
10 and 15 years of a first degree secondary school, used
the body shape questionnaire or questionnaire on bodily
dissatisfaction (BSQ) Uneasiness Test (BUT), the Scale
Rating Scale (FRS) test, and finally the detection of the
weight/height ratio as well as the Corporean Mass Index.
Methodology
The aim of this study was to analyze, through the
administration of diagnostic tests, the perception and
possible alteration of the body image, often a predictive
factor for the onset of pathologies such as Eating
Disorders.
Specifically, fundamental aspects have been consi-
dered: perceptual, cognitive and affective components
of bodily representations. The use of tests (BSQ, BUT,
FRS) has allowed us to measure the real difference that
subjects have about themselves, how they are perceived
now and how they would like to be.
The sample examined presents the characteristics of
a true experimental design, but it is only explorative and
entirely pioneering. Nevertheless, the following results
have shown interesting reflection points, although fur-
ther investigation and significant increase in the sample
size are needed to conclude a generalization of the data
so far extrapolated.
Description of Case Study Group
The sample used for this work is 100 teenagers,
divided into 53 females, 47 males aged between 10 and
14, casually identified in high school. Subjects were
given a test battery in the school during the course of a
health project to which the school adhered to during the
school year.
Testing Instruments
The intstruments used are self-administered tests
that measure the real difference that they have at their
present time and what they would like to be, that is,
which should be the actual or desired image. The
usefulness of these tests is supported by the hypothesis
that the greater the difference between the real and the
ideal dimension, the greater will be the dissatisfaction of
one's body and consequently the alteration of the mental
image of oneself. It particular:
ƒ BUT (Body Uneasiness Test), Cuzzolaro M, Vetrone
G, Marano G, Battacchi M. Body Uneasiness Test
(2000): It is a self-assessment scale of body discom-
fort that provides a global index of severity (GSP)
and a series of sub-scale scores exploring different
areas: weight dissatisfaction and fear of fatigue
(BUT scale (WP, weight phobia), excessive body-
related concerns (BIC, body image concerns),
 Maria Rosaria Juli: PERCEPTION OF BODY IMAGE IN EARLY ADOLESCENCE. AN INVESTIGATION IN SECONDARY SCHOOLS
Psychiatria Danubina, 2017; Vol. 29, Suppl. 3, pp 409-415
avoidance behaviors (But AA, avoidance) and
compulsive control (BUT A CSM, compulsive Self-
monitoring), experiencing detachment and extra-
neousness with respect to their body (scale AD,
depersonalization); In the second part of the test
(BUT B) specific concerns about certain parts, cha-
racteristics or bodily functions are summed up by
two scores: BUT.B PST, positive symptom total and
BUT. B PSDI, positive symptom distress index).
ƒ BSQ (Body shape questionnaire), Cooper PJ,
Taylor MJ, Cooper Z, Fairburn CG (1987). Self-
administered test that evaluates the concern that the
subject has of the body image; Consists of 34 items
investigating dissatisfaction with their body image in
a 4-week timeframe and based on six levels of
severity expressed by the frequency with which the
thoughts, feelings and behaviors described in the
individual items occur. As Cooper argues, the BSQ
questionnaire can not be used to measure the
occurrence of DCA cases, but rather to assess the
mental attitudes of a DCA-free population compared
to a DCA diagnosis with reference to their body
image.
ƒ The Figure Rating Scale (FRS), Thompson, JK,
Altabe MN (1991). Also known as the Stunkard
Scale is a psychometric measurement developed in
1983 as a tool to determine body dissatisfaction in
women and men. This scale has also been developed
for measuring adolescent body image. This type of
measurement was originally developed and validated
to indicate the weight status of relatives of research
subjects when other specific measurements or self-
reported values were unavailable; is a visible
measure of how an individual perceives his or her
own physical appearance. Each figure presents nine
male and nine female schematic silhouettes, ranging
from extreme thinness to extreme obesity. For
research purposes, participants are asked to self-
select the silhouette that best indicates his or her
current body size and the silhouette that reflects his
or her ideal body size.
Results
From a general reading of the test, the concern about
the physical appearance, the body dissatisfaction and the
fear of gaining weight are present among the adoles-
cents in the age between 10 and 15 years. There is no
particular evidence of the difference between males and
females. Particularly, the analyzed sample is on average
12 years old, the 50% has an IBM between 18.5 and
24.9 (normal weight), 45% has an IBM <18.5 (under-
weight) (Figure 1).
It seems that the IBM does not have a significance
impact on the perception of the body image, both in the
overweight subjects (even if just 2) and in the under-
weight ones; both resulted being dissatisfied in the same
way, independently from the gender, such as demon-
strated in the study of McCabe & Ricciarelli (2004).
IBM
18,5-24,9 <18,5 25-29,9 >=30
Figure 1. IBM
As table 1 shows, nonetheless the 45% of the sample
is underweight, in the test “Figure Rating Scale” both
males and females would rather being slimmer; the
score related to the question “how I would like to be”
are for both gender lower than the ones related to the
question “How am I”. The female gender feels to belong
to the category “normal weight” (score=3.02) but
desires being underweight (2.46); also the male gender
feels to belong to the category “normal weight” and
overweight (score=3.80) but desires belonging to the
category underweight (score=2.89). In the global score
between males and females there is the tendency of the
two genders to feel to belong to the category of “normal
weight” (score=3.38) but they would like to be in the
category underweight (score=2.66).
What emerged is bewildering, because many studies
agree on the fact that the lack of self-esteem, the desire
for a different weight and so, a global dissatisfaction for
the body is a predictive factor more reliable than the
eating behaviors themselves (Cash 2002).
The BSQ results are quite clear because just 9 sub-
jects reached a score equal to 34 (minimum score and
not significant), the other 91 individuals reached a
score higher than 34, therefore the major part of the
sample present a strong concern for his/her own
physical appearance. The maximum score reached by a
male participant in the BSQ test is 148 and the maxi-
mum female score is 170. These scores confirm that
also in the prepubescence phase there are thoughts,
sensations and behaviors concerning the weight and
the body shape.
In the table 2 half of the sample of males and fe-
males has a dissatisfaction score in the BSQ of 43 and 44
respectively, at p90 among the females the dissatis-
faction stays at 79% whereas it grows up to 89% among
males, therefore in this last distribution the male gender
results more dissatisfied than the female gender.
Considering the distribution, I counted the indivi-
duals that had a score >70 and <70, setting a cut-off that
can represent a significant body dissatisfaction; it results
that the 15.4% has a score >70 in the BSq independently
from the gender and represent a significant body
dissatisfaction.
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Table 1. BSQ results

Scores
Gender Indicators
Media Standard Deviation Median
Females BSQ 50.61 25.30 44
like I am 3.02 1.12 3
How I want to be 2.46 0.66 2
Man BSQ 52.43 23.69 43
like I am 3.80 1.28 4
How I want to be 2.89 0.97 3
M+F BSQ 51.45 24.47 43.5
like I am 3.38 1.25 3
How I want to be 2.66 0.84 3

Table 2. Dissatisfaction score in the BSQ

Gender Media Standard Deviation max min p25 p50 p75 p90
F 50.61 25.30 170 34 37 44 53 79
M 52.43 23.69 148 34 37 43 57 89
M+F 51.45 24.47 170 34 37 43.5 54 84.5

Table 3. BUT test

Scores
Gender Indicators
Media Standard Deviation Median
Females WP 1.50 0.97 1
BIC 1.50 0.97 1
A 1.50 0.97 1
CSM 1.48 0.95 1
D 1.48 0.97 1
Man WP 1.50 0.86 1
BIC 1.50 0.86 1
A 1.50 0.86 1
CSM 1.48 0.86 1
D 1.46 0.84 1
M+F WP 1.50 0.92 1
BIC 1.50 0.92 1
A 1.50 0.92 1
CSM 1.48 0.90 1
D 1.47 0.90 1

Figure 2. % Worries about getting fat by age classes - Females

Figure 3. % Worries abaut getting fat by age classes – Men

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Psychiatria Danubina, 2017; Vol. 29, Suppl. 3, pp 409-415
The BUT test, reported in table 3, highlights the
body discomfort experienced by the individuals. The
score of the sub-scales that explore the different areas
find place in scores lower than 2, therefore, indepen-
dently from the gender, the concern for the body results
being medium seized, specifically the total score of the
two genders is so divided: the dissatisfaction for the
weight and the fear to gain weight (scale BUT. A BIC,
body image concerns, score: 1.50), avoidance behavior
(scale But. A A, avoidance, score: 1.50) and the com-
pulsive control (BUT. A CSM, compulsive self-moni-
toring, score: 1.48).
The sample is split into two age classes, respectively
10-12 years and 13-15 years. As Figure 2 shows the
females of the class 10-12 result in being more concer-
ned of gaining weight, with a score of 18.8, whereas in
the class 13-15 4.6% is scared of gaining weight. The
28% of the class 10-12 has never fear of gaining weight,
whereas, we observe a score of 59.1% for the scare of
gaining weight for the class 13-15 years. In the end, a
score equal to 12.5% is highly concerned in the class
10-12 and a concerning with score 0 in the class 13-15.
Also the males, split in the same age classes as the
females, present the following percentage:
ƒ Figure 3, in both classes no male subject present the
concerning of gaining weight, always with a score
0.00.
ƒ The percentage of males belonging to the 10-12
class answering often 5.3% results significant, whe-
reas the ones of the class 13-15 years result more
concerned with a 18.5%.
Discussion
The lack of satisfaction regarding the body image is
represented by the personal sorrow for the shape of the
body in general or for the size of some parts of the
body. The psychological discrepancy between the per-
ception that we have about our own body and the body
considered as ideal can lead to a negative feeling about
ourselves and to behaviors harmful to our health (Thom-
pson 2004). Although the dissatisfaction about the body
exists specially among young people, in its extreme
condition it is considered an essential component for the
start of pathological behaviors. Indeed, the dissatis-
faction about the body can be associated with a distorted
view of the body image that can be closely related to
eating disorders. Currently we do not know exactly
what is the role of body dissatisfaction in causing or
promoting the onset of Eating Disorders and whether it
is primary to the disorder or secondary to changes in
cognitive functions determined by fasting (anorexia) or
abusing (bulimia). However, several studies, including
the one of Bruch H. (1978), highlight that there is a
close correlation between the dissatisfaction about the
body and the onset of eating disorders. Some research
conducted by Granner (2002) and Stice (2010) shows a
link between the low satisfaction for the body and many
factors related to bad health such as depression, low
self-esteem, anxiety, substance abuse and alcohol abuse.
As we have seen from the results we got, the
dissatisfaction about the body and the problems related
to the body image are becoming quite common also
among men, therefore now the problem involves women
and men without a big difference. This is happening due
to the most popular magazines for men that show
muscular bodies, in addition to movies where the same
thing happens and to the spread of products that are able
to increase the muscle mass. The first evidence of the
incongruous correlation between the effective weight
and the satisfaction about the body image appeared in
the literature in the mid-eighties of the last century
when Rodin J. et al (1985) and Cash TF (1986) found
that among the women without any clinical issue, the
percentage of those who did not show concern for their
physical appearance was derisory. Over the last twenty
years, thanks to numerous studies, the literature regar-
ding this topic has confirmed the popular association
between dissatisfaction about the body and eating
disorders, showing that attitudes about the physical
appearance are a more exact predictor of the deve-
lopment of Eating Disorders than distorted perception of
the body. The studies conducted by Stice E. in 2002
show that the pressure coming from family members,
friends and media create an ideal of "subtle beauty" and
the tendency to give excessive importance to weight and
body shapes when we evaluate ourselves. The author
states that these behaviors represent the structural basis
of a distorted view of our body which increases the
probability of developing the three typical symptoms of
food pathology: food restriction, over eating and
affective deficiency. Therefore, it is necessary to sup-
port prevention programs involving schools, places of
training and education in order to develop the creative
potentialities of adolescents and pre-adolescents enhan-
cing protective factors and increasing emotional and
cognitive awareness in order to finally promote identity
development.
Conclusions
As already said, pre-adolescence is characterized by
body dissatisfaction, which is closely linked to a more
general discomfort and insecurity regarding the identity,
therefore it is not possible to work on these specific risk
factors without relating them to the more global identity
uncertainty.
Therefore, in order to be able to intervene concretely
on "at risk" behaviors of young people, it is necessary to
work in terms of primary prevention programs that
consider the disorder as an expression of a wider
psychic discomfort, developing a deeper path to spread
the concept of "bio-psychological-social wellness" accor-
ding to the definition of health promotion. Currently
national and international studies on the effectiveness of
primary prevention interventions are few and some
analyses have highlighted the risks associated with an
incautious prevention.
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Psychiatria Danubina, 2017; Vol. 29, Suppl. 3, pp 409-415
An important prerequisite is that practitioners are
highly qualified as adolescences tend to see them as
guides and references to imitate and the topics dealt
with them can have a strong impact at this stage of life.
In particular, it is important to talk about Eating
Disorders prevention focusing on risk factors, especially
strengthening protective factors.
Temperamental, traumatic, and family risk factors
can be the basis for psychopathologies of various kinds
(depressive disorders, anxiety disorders, dissociative
disorders), especially when they are really strong.
When they are combined with risk factors for
dissatisfaction and discomfort for the body, then they
can determine the onset of eating disorders (Dalla
Ragione, 2005). Now many agree with the need of
preventive interventions to increase protective factors
already in early childhood. And it is also necessary to
involve the parents of the children and to have the
primary goal of creating a good ability to recognize
internal motivations.
In the light of these considerations, it is necessary to
define the prevention measures according to the
guidelines of the National Health Plan of 2003: "A
characteristic of the prevention of diseases linked to
nutrition is the necessity to involve the majority of the
population and not only the high-risk groups. The
prevention strategy should be addressed to the entire
population, where recommendations for healthy
nutrition and healthy dietary choices, also consistency
with cultural and socio-economic factors should be
disseminated” (National Health Plan, 2003); and the
recommendations are offered by Neumark–Sztainer
(2009). In particular:
ƒ Taking into consideration the disorder as expression
of a wider adolescent psychic discomfort and organi-
zing prevention as a large project for the dissemi-
nation of the concept of psycho-physical well-being
according to the idea of promotion of the health
from the WHO;
ƒ Taking into consideration these disorders as corre-
lated and enhanced by the current socio-cultural con-
text and then defining a prevention plan that takes
into account these external influences (mass media,
modes), but without focusing only on this;
ƒ Eating in a healthy way, promoting a healthy life-
style and enhancing psychic, physical and social
well-being. A balanced dietary style is also effective
to avoid the onset of many pathological conditions.
ƒ As part of a prevention project, it is essential to work
on personal aspects (body stimuli, habits), physio-
logical aspects related to nutrition, collective aspects
as the sociocultural ones;
ƒ We have to face together the problem that charac-
terize human existence, ranging from insignificance
to significance, from time lived to the one planned,
from protection to disposition to risk.
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The objectives of a prevention project for Eating Dis-
orders should be:
ƒ To provide information about the content and func-
tions of food and about education regarding nutrition;
ƒ To acquire a greater awareness of the relationship
between food and emotions;
ƒ To provide ideas to think about some risk factors and
the maintenance of eating disorders (cultural factors,
prejudices on obesity and anorexia);
ƒ To stimulate a good acceptance of ourselves, of our
body and our image.
This type of intervention should have the main scope
to reinforce self-esteem and to counteract the negative
impacts of the culture on health in general and can be
included in a wider prevention project of disorder that
involves young people that often, especially in cases of
eating disorders, are also victims of some behaviors
closely related (alcohol abuse, drugs, etc.). It is crucial
that this kind of educational intervention stimulates
knowledge, attitudes and behaviors that promote self-
acceptance and psycho-physical well-being in the
teenagers helping them to better understand the close
relationship between food and emotions.
Acknowledgements: None.
Conflict of interest: None to declare.
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Correspondence:
Maria Rosaria Juli, MD
Clinical Psychologist, Psychotherapist, Specialist in Alimentary Behaviour Disorders
Family Counseling of Foggia
via C. Baffi, 1, Foggia, Italy
E-mail: mariarosaria.juli@libero.it
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